Required Filing Checklist (Information should be emailed to kid.tpa@ks.gov with the wording [year] Annual Report - [company name] in the subject field.) List of Insurers/Self-Funded Plans Audited Financial Statement - If audited "consolidated" financial statement is provided, it must include an audited, itemized breakdown supplement of the TPA entity specific, per K.S.A. 40-3814(1). See EXHIBIT A below for more information regarding the Audited Financial Statement requirement. $100 Filing Fee paid upon submission of this form Company Name: DBA Name: License #: FEIN: Business Address: Mailing Address: Business Phone: Business Email: Business Website: Contact Person: Title: Contact Phone: Contact Email: Background Information Please read and answer the following questions: Yes No 1. Has there been any administrative action taken against the administrator in another jurisdiction or by another governmental agency within the last year? If you answer yes, you must provide by email to kid.tpa@ks.gov 1. a copy of the order, 2. consent order, and 3. other relevant legal documents. Yes No 2. Has any owner, partner, officer or director been involved in an administrative proceeding regarding any professional or occupational license within the last year? If you answer yes, you must provide by email to kid.tpa@ks.gov 1. a written statement identifying the type of license and explaining the circumstances of each incident, 2. a copy of the Notice of Hearing or other document that states the charges and allegations, and 3. a copy of the official document which demonstrates the resolution of the charges or any final judgment. Yes No 3. Has there been a change of officers within the last year? If you answer yes, you must provide by email to kid.tpa@ks.gov 1. list of the new officers and their positions. Yes No 4. Does the administration administer, or will be administering, self-funded health plans subject to regulation under chapter 40, Kansas Statutes Annotated? List of Insurer and Self-Funded Plans Provide a document by email to kid.tpa@ks.gov Please include the following information: List of insurer and self-funded plans the administrator had agreements with during the perceding fiscal year. Include: Insurance Company Name NAIC# Address City, State, Zip Code Contact Telephone Number Number of Kansas residents covered by plan Employer and Trust Name Address City, State, Zip Code Contact Telephone Number Number of Kansas residents covered by plan In addition, please provide the following information: Is your stop-loss carrier admitted to do business in Kansas? Yes No Please provide the name of the stop-loss carrier(s) utilized: Officers Verification The report must be verified by at least two (2) officers of the administrator Annual Report for the fiscal year ending: The officers of this reporting entity being duly sworn, each depose and say that they are the described officers of said reporting entity, and that on the reporting period stated above, all of the herein described assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this statemnet is in full and true answered of all the assets and liabilities of the condition and affairs of the said reporting entity as of the reporting period stated above and of its income and deductions therefrom for the period ended and have been completed in accordance with the Generally Accepted Accounting Principles according to the best of their information, knowledge and belief, respectively. The undersigned owner, partner, officer or director of the applicant hereby certifies, under penalty of perjury, that all of the information submitted in this reporting and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the applicant to civil or criminal penalties as determined by a court of law. Signature: Date: 03/24/2023 By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. Printed Name: Title: Signature: Date: 03/24/2023 By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. Printed Name: Title: EXHIBIT A Audited Financial Statement Requirement- K.S.A. 40-3814 -An audited financial statement is a requirement of the Annual Report. If submitting a "consolidated" audited statement, the statement must include an itemized breakdown of the TPA entity specific to comply with K.S.A. 40-3814(b). -If negative equity is reported in audited statement, additional explanatory reporting and/or financial information is required to be included in the Report which explains the deficit and supports financial soundness. -K.S.A. 40-3814(2) permits the Commissioner to grant a hardship exemption from filing the required audited financial statements and allow the submission of unaudited financial statements. Please see the "Third Party Administrator Hardship Exemption" form on our website for application procedures as well as information that would be required if an exemption was approved, including securing, and maintaining a surety bond for the greater of 10% of funds handled for the benefit of Kansas residents or $20,000.
